Get Instructions For Financial Assistance Application - Ahn - Ahn

Filling out the Instructions For Financial Assistance Application - AHN - Ahn is a critical step for individuals seeking financial assistance for medically necessary services. This guide will provide you with clear, step-by-step instructions to ensure that you complete the application accurately and effectively.

Follow the steps to complete your financial assistance application.

1. Click ‘Get Form’ button to obtain the form and open it in your preferred editor.
2. Begin by entering the patient’s personal information in the designated fields, including their full name, birthdate, and social security number.
3. Provide the home address along with contact information. Ensure that the address is complete and accurate to avoid any delays in processing your application.
4. Indicate the patient's employment details, if applicable, including the employer's name and phone number.
5. Select the marital status from the provided options and complete the spouse or guarantor's information where necessary.
6. List all household members who are claimed on the IRS form 1040, including their relationships to the patient and ages.
7. Provide information regarding home ownership, including the assessed value and mortgage details if applicable.
8. Detail any motor vehicles owned or leased by the patient or guarantor.
9. List all bank accounts along with account types, bank names, account numbers, and current balances. Attach two months of bank statements for verification.
10. Document all investments with similar information as bank accounts and attach relevant investment statements.
11. Calculate and include the total household monthly income from all sources as detailed in the form.
12. Enter all household monthly expenses, providing detailed amounts for each category listed.
13. Respond to additional questions regarding Medical Assistance applications and health insurance status.
14. Read and confirm the authorization and verification section by providing your signature, date, and printed name. Ensure that the relationship to the patient is also included.
15. Once the form is completed, ensure all copies of required proofs of income are attached as outlined in the instructions.
16. Finally, save your changes, and once ready, print or share the completed form with the necessary documents to the specified address.

Complete your financial assistance application online to access the support you need.